OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction

ICR 201210-1210-002 · OMB 1210-0135 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form Form 301 Additional Information Request to Plan Administrator Form and Instruction Modified Available
Form Form 300 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction Form and Instruction Modified Repair queued
Expedited_Review_of_Denial_of_Claims_ss12[1].docx Supporting Statement A Uploaded 2012-10-01 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
189162 Additional Information Request to Plan Administrator Form and Instruction Modified
188224 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction Form and Instruction Modified
ICR Details
1210-0135 201210-1210-002
Historical Active 201004-1210-006
DOL/EBSA
Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Extension without change of a currently approved collection   No
Regular
Approved without change 01/31/2013
Retrieve Notice of Action (NOA) 11/27/2012
  Inventory as of this Action Requested Previously Approved
01/31/2016 36 Months From Approved 01/31/2013
184 0 15,400
171 0 14,350
104 0 8,000
Section 3001 of the American Recovery and Reinvestment Act of 2009 (ARRA) provides "Assistance Eligible Individuals" with the right to pay reduced COBRA premiums for up to 9 months. If individuals request treatment as an assistance eligible individual and are denied such treatment because of their ineligibility for COBRA continuation coverage, ARRA section 3001(a)(5) requires the Secretary of Labor to provide for expedited review of the denial upon application to the Secretary in the form and manner the Secretary provides. The Secretary of Labor is required to act in consultation with the Secretary of the Treasury and must make a determination within 15 business days after receipt of an individual's application for review. The "Application to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction" (the "Application") is the form used by individuals to file their expedited review appeals. Such individuals must complete all information requested on the Application in order to file their review requests with the Department's Employee Benefits Security Administration (EBSA). The ICR relates to the Application.
PL: Pub.L. 111 - 5 3001(a)(5) Name of Law: American Recovery and Reinvestment Act of 2009
  
None
Not associated with rulemaking
  77 FR 37920 06/25/2012
77 FR 70827 11/27/2012
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 184 15,400 0 0 -15,216 0
Annual Time Burden (Hours) 171 14,350 0 0 -14,179 0
Annual Cost Burden (Dollars) 104 8,000 0 0 -7,896 0
No
No
The previous submission of this ICR reflected the Department's best efforts to estimate the hour and cost burden associated with it. The Department's current estimate is based on actual program usage data, which, as discussed in detail above, show a steady decline in the number of applications received by the Department. This has led to a reduction in the hour and cost burden estimate for this ICR.
No
No
No
No
Yes
Uncollected
Christopher Cosby 202-693-8425 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/27/2012